News

Effective January 31, 2023: Clinical Policies

Date: 11/28/22

Superior HealthPlan has added and updated certain clinical policies to ensure medical necessity review criteria is current and appropriate for members and the scope of services provided. As a result the following policies are effective on January 31, 2023, at 12:00AM.

POLICY	APPLICABLE PRODUCTS	NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (CP.MP.61)	Ambetter	Policy updates include: Changed title from “Dental Anesthesia” to “IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures” and adopted the Envolve Dental Policy criteria from ENVD.UM.CP.0009, approved 11/21 Removed HCPCS code D9230 In I Specified that general criteria in I. must be met in addition to POS-specific criteria in II or III. Clarified that A (indications), B (lack of contraindications), and C (documentation) must all be met Specified in II that absence of comorbidities applies to all indications
Orthognathic Surgery (CP.MP.202)	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter	Policy updates include: In II Reformatted criteria and added II.B. as additional non-medically necessary indication CDT codes removed from policy
Pediatric Kidney Transplant (CP.MP.246)	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter	Policy developed

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures

(CP.MP.61)

Ambetter

Policy updates include:

Changed title from “Dental Anesthesia” to “IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures” and adopted the Envolve Dental Policy criteria from ENVD.UM.CP.0009, approved 11/21
Removed HCPCS code D9230
In I
- Specified that general criteria in I. must be met in addition to POS-specific criteria in II or III. Clarified that A (indications), B (lack of contraindications), and C (documentation) must all be met
Specified in II that absence of comorbidities applies to all indications

Orthognathic Surgery

(CP.MP.202)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

In II
- Reformatted criteria and added II.B. as additional non-medically necessary indication
CDT codes removed from policy

Pediatric Kidney Transplant

(CP.MP.246)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy developed

To review all policies, please visit Superior’s Clinical, Payment & Pharmacy Policies webpage.

Prior to updates, Medical Clinical policies are reviewed and approved by the Utilization Management Committee.

For questions or additional information, contact Superior HealthPlan Prior Authorization department at 1-800-218-7508.